Prosthetic valve and delivery tool therefor

ABSTRACT

Embodiments of the present disclosure include a method for use at a native valve of a heart of a subject. At a distal portion of a delivery tool, a balloon is coupled to a shaft. The distal portion is advanced to the heart with an implant and the balloon disposed within a capsule. The implant includes a tubular frame and one or more shape-memory flanges. The tubular frame is compressed around the balloon, and the flanges are constrained within a downstream capsule-portion of the capsule. The flanges are exposed from the downstream capsule-portion such that the flanges automatically deflect radially outward. Subsequently, the flanges are pressed against a downstream surface of the native valve by moving the implant in an upstream direction. While the flanges are in contact with the downstream surface, the tubular frame is plastically expanded radially by inflating the balloon. Other embodiments are also described.

CROSS-REFERENCES TO RELATED APPLICATIONS

The present application is a Continuation of U.S. Ser. No. 16/768,909 toHariton et al., filed Jun. 2, 2020, and entitled “PROSTHETIC VALVE ANDDELIVERY TOOL THEREFOR,” which issued as U.S. Pat. No. 11,382,746, andwhich is the US National Phase of PCT application IL2018/051350 toHariton et al., filed Dec. 12, 2018, and entitled “PROSTHETIC VALVE ANDDELIVERY TOOL THEREFOR,” which published as WO/2019/116369, and whichclaims priority from UK patent application GB 1720803.4, filed Dec. 13,2017, and entitled “Prosthetic valve and delivery tool therefor.”

Each of the applications mentioned above is assigned to the assignee ofthe present application and is incorporated herein by reference.

FIELD OF THE INVENTION

Some applications of the present invention relate in general topercutaneous delivery of medical implants. More specifically, someapplications of the present invention relate to prosthetic cardiacvalves and techniques for implantation thereof.

BACKGROUND

Dilation of the annulus of a heart valve, such as that caused byischemic heart disease, prevents the valve leaflets from fully coaptingwhen the valve is closed. Regurgitation of blood from the ventricle intothe atrium results in increased total stroke volume and decreasedcardiac output, and ultimate weakening of the ventricle secondary to avolume overload and a pressure overload of the atrium.

SUMMARY OF THE INVENTION

An implant is provided having self-expanding portions, andnon-self-expanding portions. The implant comprises a non-self-expandingtubular frame, which is balloon-expandable. The implant furthercomprises an outer frame, which comprises self-expanding flanges and aself-expanding upstream support portion. The self-expanding nature ofthe flanges and upstream support portion is provided by the outer framebeing composed of a shape-memory alloy. The tubular frame is composed ofa different material.

The outer frame is coupled to the tubular frame via pins that arecomposed of the same material as the tubular frame. One end of each pinis secured to the outer frame by a head of the pin. The other end ofeach pin is secured to the tubular frame by welding.

A delivery tool comprises a capsule that has two capsule-portions, oneto constrain the flanges, and one to constrain the upstream supportportion. The delivery tool further comprises a balloon, disposed withinthe tubular frame. At the implantation site, the flanges and upstreamsupport portion are released from the capsule, and automatically deflectradially outwards. Subsequently, the balloon is inflated to radiallyexpand the tubular frame.

The delivery tool further comprises projections, which are sufficientlyrigid to axially push the tubular frame in order to press the flangesagainst tissue at the implantation site, but which are sufficientlyflexible to not inhibit inflation of the balloon.

There is therefore provided, in accordance with an application of thepresent invention, apparatus for use at a native valve of a heart of asubject, the apparatus including:

-   -   a delivery tool, including:        -   a shaft, having a shaft-axis;        -   a capsule, disposed at a distal portion of the tool, and            including an upstream capsule-portion and a downstream            capsule-portion, the capsule being openable by moving the            upstream capsule-portion and the downstream capsule-portion            apart; and        -   a balloon, coupled to the shaft, and disposed within the            capsule; and    -   a prosthetic valve, including:        -   a tubular frame, compressed around the balloon, and disposed            within the capsule;        -   one or more shape-memory flanges, constrained within the            downstream capsule-portion; and        -   a shape-memory upstream support portion, constrained within            the upstream capsule-portion,            and:    -   the flanges are configured to automatically deflect radially        outward upon exposure from the downstream capsule-portion,    -   the upstream support portion is configured to automatically        deflect radially outward upon exposure from the upstream        capsule-portion,    -   the tubular frame is configured to remain compressed around the        balloon upon exposure of the tubular frame from the capsule, and    -   while the tubular frame is exposed from the capsule, inflation        of the balloon plastically expands the tubular frame radially.

In an application, the prosthetic valve further includes one or moreprosthetic valve leaflets disposed within the lumen and coupled to thetubular frame.

In an application, the tubular frame is disposed within the downstreamcapsule-portion of the capsule.

In an application, the tubular frame is composed of a material that isnot a shape-memory alloy.

In an application, the tubular frame is composed of steel.

In an application, the tubular frame is composed of cobalt chrome.

In an application, the flanges are composed of a shape-memory alloy.

In an application, the flanges are composed of nickel titanium.

In an application, the balloon is fixed to the shaft.

In an application, both the upstream capsule-portion and the downstreamcapsule-portion are axially movable with respect to the shaft.

In an application:

-   -   a first capsule-portion selected from the group consisting of:        the upstream capsule-portion and the downstream capsule-portion        is attached to a tube, and is axially movable with respect to        the shaft by the tube being slid over the shaft, and    -   a second capsule-portion selected from the group is attached to        a rod, and is axially movable with respect to the shaft by the        rod being slid though the shaft.

In an application, the upstream capsule-portion is retractable from overthe upstream support portion by being moved away from the balloon, andthe downstream capsule-portion is retractable from over the flanges bybeing moved away from the balloon.

In an application, the delivery tool further includes one or moreelongate projections disposed within the downstream capsule-portion,each of the projections having (i) a tip-portion, and (ii) abase-portion, disposed deeper than the tip-portion into the downstreamcapsule-portion, the projections arranged circumferentially around theshaft-axis such that the tip-portions are arranged circumferentiallyaround a downstream balloon-portion of the balloon, with the tip-portionof each projection being closer than its corresponding base-portion tothe tubular frame.

In an application, each of the projections is sufficiently stiff that,when pushed against the tubular frame, it is capable of applying, to thetubular frame, an axial pushing force of at least 0.5 N.

In an application, each of the projections is sufficiently stiff that,when pushed against the tubular frame, the one or more projections arecapable collectively of applying, to the tubular frame, an axial pushingforce of at least 3 N.

In an application, when pushed against the tubular frame, the one ormore projections are capable collectively of applying, to the tubularframe, an axial pushing force of at least 3 N and no more than 100 N.

In an application, when pushed against the tubular frame, the one ormore projections are capable collectively of applying, to the tubularframe, an axial pushing force of at least 3 N and no more than 30 N.

In an application, when pushed against the tubular frame, the one ormore projections are capable collectively of applying, to the tubularframe, an axial pushing force of at least 6 N and no more than 30 N.

In an application, when pushed against the tubular frame, the one ormore projections are capable collectively of applying, to the tubularframe, an axial pushing force of at least 40 N and no more than 100 N.

In an application, when pushed against the tubular frame, the one ormore projections are capable collectively of applying, to the tubularframe, an axial pushing force of at least 40 N and no more than 80 N.

In an application, when pushed against the tubular frame, the one ormore projections are capable collectively of applying, to the tubularframe, an axial pushing force of at least 60 N and no more than 100 N.

In an application, the tubular frame is disposed within the downstreamcapsule-portion of the capsule, and the downstream capsule-portion isretractable from over the tubular frame and at least the tip-portions,exposing, from the downstream capsule-portion, the tubular frame and atleast the tip-portions.

In an application, while the tubular frame and the tip-portions areexposed from the downstream capsule-portion, inflation of the balloon(i) radially expands the tubular frame, and (ii) deflects each of theprojections radially outward within a respective radial plane on whichthe shaft-axis and the projection lie.

In an application, while the tubular frame and the tip-portions areexposed from the downstream capsule-portion, inflation of the balloonuniformly fills the lumen of the tubular frame.

In an application, a widest part of the balloon is disposed within thelumen.

In an application, each projection has a radial stiffness in its radialplane, and has a lateral stiffness in a respective lateral plane, thelateral stiffness being greater than the radial stiffness.

In an application:

-   -   the balloon has an upstream balloon-portion, a downstream        balloon-portion, and a body balloon-portion therebetween,    -   the tubular frame is compressed around the body balloon-portion,        and    -   while the tubular frame and the tip-portions are exposed from        the downstream capsule-portion, inflation of the balloon (i)        radially expands the tubular frame by pressing the body        balloon-portion radially outward against the tubular frame,        and (ii) deflects the projections radially outward by pressing        the downstream balloon-portion radially outward against the        projections.

In an application, the downstream balloon-portion of the balloon extendsaway from the tubular frame, and is tapered.

In an application, the upstream balloon-portion of the balloon extendsaway from the tubular frame, and is tapered.

In an application, the tip-portion of each of the projections abuts thetubular frame, and the apparatus is configured such that the tip-portionof each of the projections remains in contact with the tubular frame asthe balloon is inflated.

In an application, a downstream end of the tubular frame defines aframe-circumference, the tip-portions define a projection-circumference,and while the tubular frame and the tip-portions are exposed from thedownstream capsule-portion, inflation of the balloon increases theprojection-circumference at the same rate as the balloon increases theframe-circumference.

In an application, the tip-portion of each of the projections abuts thetubular frame.

In an application, the projections are not attached to the tubularframe.

There is further provided, in accordance with an application of thepresent invention, apparatus for delivery of a prosthetic heart valve toan annulus of a native heart valve, the apparatus including:

-   -   a shaft, having a longitudinal shaft-axis;    -   an inflatable balloon, disposed at a distal end of the shaft;        and    -   one or more projections extending distally from the shaft, such        that the projections are arranged around a proximal portion of        the balloon,        and:    -   inflation of the balloon causes radial expansion of the balloon,        the radial expansion of the balloon applying a radial force to        each of the projections, and    -   each of the projections is sufficiently radially flexible that        the radial force deflects the projections radially outward.

In an application, for each of the projections:

-   -   the projection defines:        -   a respective radial plane on which the shaft-axis and the            projection lie, and within which the projection deflects in            response to the radial force, and        -   a lateral plane, tangential to the circumference, and on            which the projection lies,    -   the projection has a radial stiffness, in its radial plane, and    -   the projection has a lateral stiffness, in its lateral plane,        that is greater than the radial stiffness.

In an application, the apparatus further includes a tubular frame at thedistal end of the shaft, the tubular frame defining a longitudinallumen, and the balloon is disposed within the lumen.

In an application, each of the projections is sufficiently stiff that itis capable of applying, to the tubular frame, an axial pushing force ofat least 0.5 N.

In an application, each of the projections is sufficiently stiff thatthe one or more projections are capable collectively of applying, to thetubular frame, an axial pushing force of at least 3 N.

In an application, the apparatus further includes one or more prostheticvalve leaflets disposed within the lumen and coupled to the tubularframe.

In an application, the balloon:

-   -   has a longitudinal balloon-axis, collinear with the longitudinal        shaft-axis, the balloon-axis extending through the lumen,    -   has (i) a deflated state, and (ii) an inflated state in which        the balloon has a widest part, and    -   is positioned with respect to the tubular frame such that the        widest part is within the lumen.

In an application, the balloon, in its inflated state, uniformly fillsthe lumen.

In an application, in the inflated state of the balloon, the proximalportion of the balloon tapers proximally away from the tubular frame.

In an application, the balloon, in its inflated state, has a tapereddistal portion that tapers distally away from the tubular frame.

In an application, the widest part of the balloon is disposedlongitudinally between the proximal portion and the distal portion.

In an application, each of the projections has a tip-portion that abutsa proximal surface of the tubular frame.

In an application, the tip-portion of each of the projections is notattached to the tubular frame.

In an application, inflation of the balloon simultaneously increases (i)a radial distance between the tip-portion of one of the projections andthe tip-portion of an opposite one of the projections, and (ii) acircumference of the tubular frame.

There is further provided, in accordance with an application of thepresent invention, apparatus for use in a heart of a subject, theapparatus including:

-   -   a tubular frame that circumscribes a longitudinal axis to define        a lumen along the longitudinal axis;    -   a valve member, disposed within the lumen and coupled to the        tubular frame;    -   an outer frame:        -   disposed radially outward from the tubular frame,        -   including a flange, and        -   defining an eyelet; and    -   a pin:        -   defining a shaft and a head, and        -   coupling the outer frame to the tubular frame,            and:    -   the outer frame is composed of a shape-memory alloy,    -   the tubular frame and the pin are composed of a material that is        not the shape-memory alloy,    -   the head is disposed against the outer frame, radially outward        from the eyelet,    -   the shaft extends from the head through the eyelet to the        tubular frame, and    -   the shaft is welded to the tubular frame.

In an application, the outer frame further includes an upstream supportportion, shape-set to extend radially outward from the tubular frame.

In an application, the flange is shape-set to extend radially outwardfrom the tubular frame.

In an application, the outer frame further includes an upstream supportportion, upstream support portion is shape-set to extend radiallyoutward from the tubular frame, and the flange is shape-set to extendradially outward from the tubular frame and toward the upstream supportportion.

In an application:

-   -   the flange has a root-portion and a tip, and extends away from        the tubular frame from the root-portion to the tip,    -   the eyelet is defined at the root-portion of the flange, and    -   the head is disposed against the root-portion of the flange,        radially outward from the eyelet.

In an application, the eyelet is an outer eyelet, and the tubular framedefines an inner eyelet, the shaft extending through the inner eyelet.

In an application, the shape-memory alloy is nickel titanium.

In an application, the material is not a shape-memory material.

In an application, the material is steel.

In an application, the material is cobalt chrome.

In an application, the flange is one of a plurality of flanges, and theouter frame includes the plurality of flanges, and circumscribes thetubular frame.

In an application, the eyelet is one of a plurality of eyelets, and theouter frame defines the plurality of eyelets.

In an application, the flanges of the plurality of flanges are equal innumber to the eyelets of the plurality of eyelets.

In an application, the eyelet is one of a plurality of eyelets, and theroot-portion of each flange of the plurality of flanges defines arespective eyelet of the plurality of eyelets.

There is further provided, in accordance with an application of thepresent invention, a method for constructing a prosthetic heart valve,the method including:

-   -   from a tube of a shape-memory alloy, cutting an outer frame that        includes a flange and defines an eyelet;    -   from a tube of a material that is not the shape-memory alloy,        cutting a tubular frame that circumscribes a longitudinally axis        to define a lumen along the longitudinal axis;    -   positioning the outer frame against the tubular frame,        radially-outward from the tubular frame;    -   passing a shaft of a pin through the eyelet such that (i) the        shaft of the eyelet extends to the tubular frame, and (ii) a        head of the pin is disposed against the outer frame radially        outward from the eyelet, the pin being composed of the material;    -   welding the shaft to the tubular frame;    -   lining at least part of the lumen with a lining; and    -   securing a plurality of prosthetic leaflets within the lumen.

In an application, the method further includes shape-setting the flangeto extend radially outward.

In an application:

-   -   cutting the outer frame includes cutting the outer frame such        that the flange has a root-portion and a tip, and defines the        eyelet at the root-portion, and    -   passing the shaft of the pin through the eyelet such that the        head of the pin is disposed against the outer frame radially        outward from the eyelet, includes passing the shaft of the pin        through the eyelet such that the head of the pin is disposed        against the root-portion of the flange, radially outward from        the eyelet.

In an application:

-   -   the eyelet is an outer eyelet, and cutting the tubular frame        includes cutting the tubular frame such that the tubular frame        defines an inner eyelet, and    -   the step of passing the shaft includes passing the shaft through        the outer eyelet and through the inner eyelet, and    -   welding the shaft to the tubular frame includes welding the        shaft to the tubular frame at the inner eyelet.

In an application, the shape-memory alloy is nickel titanium, andcutting the outer frame from the tube of the shape-memory alloy includescutting the outer frame from a tube of nickel titanium.

In an application, the material is not a shape-memory material, andcutting the tubular frame includes cutting the tubular frame from thematerial that is not a shape-memory material.

In an application, the material is steel, and cutting the tubular framefrom the tube of the material includes cutting the tubular frame from atube of steel.

In an application, the material is cobalt chrome, and cutting thetubular frame from the tube of the material includes cutting the tubularframe from a tube of cobalt chrome.

In an application, cutting the outer frame includes cutting the outerframe that further includes an upstream support portion.

In an application, the method further includes shape-setting theupstream support portion to extend radially outward.

In an application:

-   -   the flange is one of a plurality of flanges,    -   cutting the outer frame includes cutting the outer frame such        that the outer frame defines the plurality of flanges, and    -   positioning the outer frame includes positioning the outer frame        such that the outer frame circumscribes the tubular frame.

In an application, the eyelet is one of a plurality of eyelets, andcutting the outer frame includes cutting the outer frame such that theouter frame defines the plurality of eyelets.

In an application, cutting the outer frame includes cutting the outerframe such that the outer frame has an equal number of flanges andeyelets.

There is further provided, in accordance with an application of thepresent invention, a method for use at a native valve of a heart of asubject, the method including:

-   -   advancing, to the heart, an implant that includes a tubular        frame, the tubular frame disposed on a distal portion of a tool,        the distal portion of the tool including:        -   a distal end of a shaft,        -   an inflatable balloon, having a body portion that is            disposed within the tubular frame,        -   one or more projections extending, from the shaft, distally            over at least a proximal portion of the balloon toward the            tubular frame, the proximal portion of the balloon being            proximal from the body balloon-portion of the balloon;    -   pushing the projections distally against the tubular frame to        apply a distal pushing force to the tubular frame; and    -   while maintaining contact between the projections and the        tubular frame, inflating the balloon such that:        -   radial expansion of the body balloon-portion radially            expands the tubular frame, and        -   radial expansion of the proximal portion deflects the            projections radially outward.

In an application, pushing the projections distally against the tubularframe comprises pushing the projections distally against the tubularframe such that the projections collectively apply a distal pushingforce of at least 3 N to the tubular frame.

In an application, pushing the projections distally against the tubularframe comprises pushing the projections distally against the tubularframe such that the projections collectively apply a distal pushingforce of at least 3 N and no more than 100 N.

In an application, pushing the projections distally against the tubularframe comprises pushing the projections distally against the tubularframe such that the projections collectively apply a distal pushingforce of at least 3 N and no more than 30 N.

In an application, pushing the projections distally against the tubularframe comprises pushing the projections distally against the tubularframe such that the projections collectively apply a distal pushingforce of at least 6 N and no more than 30 N.

In an application, pushing the projections distally against the tubularframe comprises pushing the projections distally against the tubularframe such that the projections collectively apply a distal pushingforce of at least 40 N and no more than 100 N.

In an application, pushing the projections distally against the tubularframe comprises pushing the projections distally against the tubularframe such that the projections collectively apply a distal pushingforce of at least 40 N and no more than 80 N.

In an application, pushing the projections distally against the tubularframe comprises pushing the projections distally against the tubularframe such that the projections collectively apply a distal pushingforce of at least 60 N and no more than 100 N.

In an application:

-   -   the implant includes one or more self-expanding flanges,    -   the tool distal portion of the tool includes a capsule;    -   advancing the implant includes advancing the tubular frame while        at least the flanges are disposed within, and constrained by,        the capsule,    -   the method further includes, prior to pushing the projections        distally, allowing the flanges to self-expand by exposing the        flanges from the capsule, and    -   the step of pushing the projections distally against the tubular        frame includes pushing the implant distally such that the        flanges press against tissue of the native valve.

In an application, advancing the implant includes advancing the implantwhile the projections are disposed within the capsule, and exposing theflanges from the capsule includes retracting the capsule proximally withrespect to the implant such that the flanges and the projections becomeexposed from the capsule.

There is further provided, in accordance with an application of thepresent invention, a method for use at a native valve of a heart of asubject, the method including:

-   -   advancing, to the heart:        -   a distal portion of a delivery tool, the delivery tool            including:            -   a shaft that extends to the distal portion of the                delivery tool,            -   a capsule disposed at the distal portion of the delivery                tool, and including an upstream capsule-portion and a                downstream capsule-portion, and            -   a balloon, coupled to the shaft, and disposed at least                partly within the capsule, and        -   an implant disposed within the capsule, and including a            tubular frame and one or more shape-memory flanges, the            tubular frame compressed around the balloon, and the flanges            constrained within the downstream capsule-portion;    -   exposing the flanges from the downstream capsule-portion such        that the flanges automatically deflect radially outward;    -   subsequently, pressing the flanges against a downstream surface        of the native valve by moving the implant in an upstream        direction; and    -   while the flanges are in contact with the downstream surface,        plastically expanding the tubular frame radially by inflating        the balloon.

In an application, plastically expanding the tubular frame includesplastically expanding the tubular frame by radially by inflating theballoon while continuing to press the flanges against the downstreamsurface.

In an application, exposing the flanges from the downstreamcapsule-portion includes moving the downstream capsule-portion away fromthe upstream capsule-portion.

In an application, advancing the implant includes advancing the implantwhile the tubular frame is disposed within the downstreamcapsule-portion, and the method further includes exposing the tubularframe from the downstream capsule-portion.

In an application, exposing the tubular frame from the downstreamcapsule-portion includes exposing the tubular frame from the downstreamcapsule-portion prior to the step of pressing the flanges.

In an application, exposing the tubular frame from the downstreamcapsule-portion includes exposing the tubular frame entirely from thedownstream capsule-portion without causing the tubular frame to expand.

In an application, the implant further includes a shape-memory upstreamsupport portion, constrained within the upstream capsule-portion, andthe method further includes, prior to expanding the tubular frame,exposing the upstream support portion from the upstream capsule-portionsuch that the upstream support portion automatically deflects radiallyoutward.

In an application, moving the implant in the upstream direction includesmoving the implant such that the upstream support portion, constrainedwithin the upstream capsule portion, is disposed upstream of the nativevalve, and exposing the upstream support portion includes exposing theupstream support portion such that the upstream support portionautomatically deflects radially outwards and contacts an upstreamsurface of the native valve.

In an application:

-   -   the implant is compressed around a body balloon-portion of the        balloon,    -   the tool further includes one or more projections, each of the        projections having a base-portion and a tip-portion,    -   the projections extend, from the shaft, over at least a        downstream balloon-portion of the balloon toward the tubular        frame, such that the tip-portion of each of the projections is        closer than its corresponding base-portion to the tubular frame,        and    -   pressing the flanges against the downstream surface by moving        the implant in the upstream direction includes pushing the        implant in the upstream direction by pushing the tip-portions        against the tubular frame.

In an application, expanding the tubular frame includes inflating theballoon such that (i) the body balloon-portion radially expands thetubular frame by pressing radially outward against the tubular frame,and (ii) the downstream balloon-portion deflects the projectionsradially outward by pressing radially outward against the projections.

In an application, advancing the distal portion of the delivery toolincludes advancing the distal portion of the delivery tool while theprojections are disposed within the downstream capsule-portion, and themethod further includes, prior to radially expanding the tubular frame,exposing at least the tips of the projections from the downstreamcapsule-portion.

In an application, exposing at least the tips of the projections fromthe downstream capsule-portion includes exposing at least the tips ofthe projections from the downstream capsule-portion prior to pressingthe flanges against the downstream surface of the native valve.

There is further provided, in accordance with an application of thepresent invention, a method for use at a native valve of a heart of asubject, the method including:

-   -   advancing, to the heart:        -   a distal portion of a delivery tool, the delivery tool            including:            -   a shaft that extends to the distal portion of the                delivery tool,            -   a capsule disposed at the distal portion of the delivery                tool, and            -   a balloon, coupled to the shaft, and        -   an implant disposed within the capsule, and including a            tubular frame and an array of shape-memory flanges arranged            around an outside of the tubular frame, the tubular frame            compressed around the balloon, and the flanges constrained            within the capsule;    -   subsequently, exposing the flanges from the capsule such that        the flanges automatically deflect radially outward away from the        tubular frame, and such that the array defines an inter-flange        distance;    -   subsequently, by partially inflating the balloon to a        partially-inflated state:        -   (i) partially radially expanding the tubular frame, and (ii)            partially increasing the inter-flange distance;    -   while the balloon remains in the partially-inflated state,        pressing the flanges against a downstream surface of the native        valve by moving the implant in an upstream direction; and    -   subsequently, by further inflating the balloon to a        further-inflated state, further radially expanding the tubular        frame.

In an application, inflating the balloon to a further-inflated statefurther includes increasing the inter-flange distance.

In an application:

-   -   exposing the flanges includes exposing the flanges while the        flanges are positioned upstream of the native valve; and    -   the method further includes, prior to pressing the flanges        against the downstream surface of the native valve, moving the        exposed flanges to be downstream of the native valve.

In an application, partially inflating the balloon includes partiallyinflating the balloon while the flanges are positioned upstream of thenative valve.

In an application, inflating the balloon to the further-inflated stateincludes inflating the balloon to the further-inflated state whilecontinuing to press the flanges against the downstream surface.

In an application, exposing the flanges from the capsule includes movinga downstream capsule-portion of the capsule away from an upstreamcapsule-portion of the capsule.

In an application, advancing the implant includes advancing the implantwhile the tubular frame is disposed within the downstreamcapsule-portion, and the method further includes exposing the tubularframe from the downstream capsule-portion.

In an application, exposing the tubular frame from the downstreamcapsule-portion includes exposing the tubular frame from the downstreamcapsule-portion prior to pressing the flanges against the downstreamsurface of the native valve.

In an application, exposing the tubular frame from the downstreamcapsule-portion includes exposing the tubular frame entirely from thedownstream capsule-portion without causing the tubular frame to expand.

In an application, the implant further includes a shape-memory upstreamsupport portion, constrained within the capsule, and the method furtherincludes, subsequent to pressing the flanges against a downstreamsurface of the native valve, exposing the upstream support portion fromthe capsule such that the upstream support portion automaticallydeflects radially outward.

In an application, exposing the upstream support portion includesexposing the upstream support portion such that the upstream supportportion contacts an upstream surface of the native valve.

In an application:

-   -   advancing the implant disposed within the capsule, the tubular        frame compressed around the balloon, includes advancing the        implant disposed within the capsule, the tubular frame        compressed around a body balloon-portion of the balloon;    -   the distal portion of the delivery tool includes one or more        projections, each of the projections having a base-portion and a        tip-portion;    -   advancing the distal portion of the delivery tool includes        advancing the distal portion of the delivery tool while the one        or more projections extend, from the shaft, over at least a        downstream balloon-portion of the balloon toward the tubular        frame, such that the tip-portion of each of the projections is        closer than its corresponding base-portion to the tubular frame;        and    -   pressing the flanges against the downstream surface by moving        the implant in the upstream direction includes pushing the        implant in the upstream direction by pushing the tip-portions        against the tubular frame.

In an application, inflating the balloon includes inflating the balloonsuch that (i) the body balloon-portion radially expands the tubularframe by pressing radially outward against the tubular frame, and (ii)the downstream balloon-portion deflects the projections radially outwardby pressing radially outward against the projections.

In an application, advancing the distal portion of the delivery toolincludes advancing the distal portion of the delivery tool while theprojections are disposed within the capsule, and the method furtherincludes, prior to partially radially expanding the tubular frame,exposing at least the tip-portions of the projections from the capsule.

There is further provided, in accordance with an application of thepresent invention, an apparatus for delivery of a prosthetic heart valveto an annulus of a native heart valve, the apparatus including:

-   -   a shaft, having a longitudinal shaft-axis;    -   a capsule, disposed at a distal portion of the shaft;    -   a balloon, coupled to the shaft, and disposed within the        capsule;    -   one or more projections extending distally from the shaft, such        that the projections are arranged around a proximal portion of        the balloon; and    -   a prosthetic valve, including a tubular frame, compressed around        the balloon, and disposed within the capsule;        and:    -   the tubular frame is configured to remain compressed around the        balloon upon exposure of the tubular frame from the capsule,        such that:        -   inflation of the balloon to a partially-inflated state            partially radially expands the tubular frame, and        -   inflation of the balloon to a further-inflated state further            radially expands the tubular frame;    -   inflation of the balloon applies a radial force to each of the        projections; and    -   each of the projections is:        -   sufficiently radially flexible that the radial force            deflects the projections radially outward,        -   sufficiently rigid to axially push the tubular frame while:            -   the balloon is in the partially-inflated state within                the tubular frame, and            -   the projections are radially outwardly deflected by the                balloon in the partially-inflated state.

The present invention will be more fully understood from the followingdetailed description of applications thereof, taken together with thedrawings, in which:

BRIEF DESCRIPTION OF THE DRAWINGS

FIGS. 1A-I are schematic illustrations of an implant, in accordance withsome applications of the invention;

FIGS. 2A-D are schematic illustration of a tool, in accordance with someapplications of the invention;

FIGS. 3A-H are schematic illustrations showing the tool being used todeliver the implant to a native valve of a heart of a subject, inaccordance with some applications of the invention;

FIGS. 4A-B, 5A-B, and 6A-B, are schematic illustrations ofimplant-delivery tools, in accordance with some applications of theinvention; and

FIGS. 7A-H and 8A-C are schematic illustrations of additionalembodiments of implant-delivery tools, in accordance with someapplications of the invention.

DETAILED DESCRIPTION OF EMBODIMENTS

Reference is made to FIGS. 1A-I, which are schematic illustrations of animplant 20, in accordance with some applications of the invention.

Implant 20 comprises a tubular frame 30 that circumscribes alongitudinal axis ax1 to define a lumen 32 along axis ax1. Implant 20typically further comprises at least one valve member (e.g., prostheticleaflet 62) (FIG. 1I), disposed within lumen 32, and coupled to frame30. Therefore implant 20 typically comprises or serves as a prostheticvalve 22.

Implant 20 further comprises an outer frame 40 and one or more pins 50.Outer frame 40 is disposed radially outward from tubular frame 30,comprises one or more flanges 42, and defines one or more eyelets, e.g.,outer eyelets 44. Typically, frame 40 comprises a plurality of flanges(e.g., 3-18, such as 6-12, such as 8-12 flanges). Typically, frame 40defines a plurality of eyelets 44 (e.g., 3-18, such as 6-12, such as8-12 eyelets). For some applications, the number of eyelets 44 is equalto the number of flanges. Further typically, the number of pins 50 isequal to the number of eyelets 44. In the embodiment shown, there are 12eyelets, 12 flanges, and 12 pins.

Typically, and as shown, frame 40 circumscribes tubular frame 30. Forexample, frame 40 may comprise at least one ring 46 that circumscribestubular frame 30, and to which flanges 42 are coupled. Ring 46 typicallydefines alternating peaks and troughs, e.g., being zigzag or wavy inshape.

Typically, tubular frame 30 also defines one or more eyelets, e.g.,inner eyelets 34. Typically, frame 30 defines a plurality of eyelets 34(e.g., 3-18, such as 6-12, such as 8-12 eyelets). Typically, the numberof eyelets 34 is equal to the number of eyelets 44.

Outer frame 40 is composed of a shape-memory alloy such as nickeltitanium (e.g., Nitinol), whereas tubular frame 30 and pins 50 arecomposed of a material that is not the shape-memory alloy. That is,frame 30 and pins 50 are both composed of the same material, and thatmaterial is not the shape-memory alloy of which frame 40 is composed.Typically, the material of which frame 30 and pins 50 are composed isnot a shape-memory material of any kind. For example, frame 30 and pins50 may be composed of steel (e.g., stainless steel, such as 316LVM) or acobalt chrome alloy (e.g., MP35N or L605). It is to be noted thatthroughout this patent application (including the specification and theclaims) the term “composed of” x means that x is the primary substancefrom which an element is made, such that x confers its properties on theelement that is made of x.

Pins 50 couple outer frame 40 to tubular frame 30. Each pin 50 defines ashaft 52 and a head 54. Shaft 52 is passed radially-inwardly through aneyelet 44 to tubular frame 30, such that head 54 is disposed againstouter frame 40, radially outward from the eyelet 44. Shaft 52 is weldedto tubular frame 30. Typically, shaft 52 is also passed radiallyinwardly through a respective eyelet 34, and is welded to tubular frame30 at eyelet 34. Because pin 50 and frame 30 are both composed of thesame material, they may be welded together. In contrast, frame 40 iscomposed of a different material than pin 50, and coupling therebetweenis provided by head 54, which is larger than eyelet 44.

Typically, each flange 42 has a root-portion 41 and a tip 43, andextends away from the tubular frame from the root-portion to the tip.Each outer eyelet 44 is typically defined at (e.g., by) the root-portion41 of a respective flange 42, e.g., such that the head 54 of therespective pin 50 is disposed against the root-portion of the flange,radially outward from the eyelet.

There is therefore provided, in accordance with some applications of theinvention, apparatus for use in a heart of a subject, the apparatuscomprising:

-   -   a tubular frame that circumscribes a longitudinal axis to define        a lumen along the longitudinal axis;    -   a valve member, disposed within the lumen and coupled to the        tubular frame;    -   an outer frame:        -   disposed radially outward from the tubular frame,        -   comprising a flange, and        -   defining an eyelet; and    -   a pin:        -   defining a shaft and a head, and        -   coupling the outer frame to the tubular frame,    -   wherein:        -   the outer frame is composed of a shape-memory alloy,        -   the tubular frame and the pin are composed of a material            that is not the shape-memory alloy,        -   the head is disposed against the outer frame, radially            outward from the eyelet,        -   the shaft extends from the head through the eyelet to the            tubular frame, and        -   the shaft is welded to the tubular frame.

Typically, frame 40 is cut from a tube of the shape-memory alloy.Typically, frame 30 is cut (e.g., laser cut) from a tube of the othermaterial. In order to facilitate implant 20 serving as a prostheticheart valve, lumen 32 is typically lined with a lining 60 (e.g.,comprising a fabric), and a plurality of prosthetic leaflets 62 (e.g.,comprising bovine pericardium) are secured within the lumen, e.g., bysuturing the leaflets to lining 36 and/or to frame 30. For the sake ofclarity, lining 60, leaflets 62, and other fabric elements are omittedin FIGS. 1A-H.

There is therefore further provided, in accordance with someapplications of the invention, a method for constructing implant 20(e.g., a prosthetic heart valve), the method comprising:

-   -   from a tube of a shape-memory alloy, cutting an outer frame that        comprises a flange and defines an eyelet;    -   from a tube of a material that is not the shape-memory alloy,        cutting a tubular frame that circumscribes a longitudinally axis        to define a lumen along the longitudinal axis;    -   positioning the outer frame against the tubular frame,        radially-outward from the tubular frame;    -   passing a shaft of a pin through the eyelet such that (i) the        shaft of the eyelet extends to the tubular frame, and (ii) a        head of the pin is disposed against the outer frame radially        outward from the eyelet, the pin being composed of the material;    -   welding the shaft to the tubular frame;    -   lining at least part of the lumen with a lining; and    -   securing a plurality of prosthetic leaflets within the lumen.

Typically, and as shown, implant 20 further comprises an upstreamsupport portion 48, e.g., comprising a plurality of radial arms 49optionally covered in an annular sheet. Further typically, it is outerframe 40 that defines upstream support portion 48, and therefore theupstream support portion is also composed of the shape-memory alloy.Flanges 42 extend radially outward from tubular frame 30, and towardupstream support portion 48. As discussed in more detail hereinbelow,flanges 42 are configured to engage a downstream surface of a nativeheart valve, and upstream support portion is configured (e.g., shapedand/or dimensioned) to be placed against an upstream surface of thenative heart valve.

Frame 40 is shaped and memory-set such that, when unconstrained,upstream support portion 48 and flanges 42 extend radially outward fromtubular frame 30. Typically, when unconstrained, flanges 42 are arrangedin an array 56 around the outside of tubular frame 30, the arraydefining an inter-flange distance D58. Although inter-flange distanceD58 is shown in FIG. 1G as a distance between opposing flanges 42, insome embodiments the inter-flange distance may refer to an alternativemeasurement (e.g., a distance between adjacent flanges 42). As discussedhereinbelow (e.g., with reference to FIGS. 3A-H), implant 20 isdelivered while radially compressed (i.e., “crimped”), with upstreamsupport portion 48 and flanges 42 constrained within a capsule. Becauseframe 40 is composed of the shape-memory alloy, upon being exposed fromthe capsule upstream support portion 48 and flanges 42 automaticallydeflect radially outward. In contrast, although tubular frame 30 is alsoradially compressed during delivery, it retains its radially-compressedstate upon being exposed from the capsule, and is subsequentlyplastically-expanded, e.g., using a balloon. Typically, in the absenceof frame 30, frame 40 (e.g., ring 46) would automatically radiallyexpand upon being exposed from the capsule. However, because frame 40 iscoupled to frame 30 (e.g., via pins 50), frame 30 inhibits frame 40(e.g., ring 46 thereof) from radially expanding until frame 30 isplastically expanded. That is, despite the elasticity of frame 40, frame30 is typically sufficiently rigid to inhibit frame 40 fromautomatically radially expanding upon exposure from the capsule.Similarly, the elasticity of frame 40 is typically insufficient to pullframe 30 into its radially expanded state (i.e., the state in whichimplant 20 functions as a prosthetic valve).

Reference is made to FIGS. 2A-D, which are schematic illustration of atool 100, in accordance with some applications of the invention. Forsome applications, tool 100 is used to implant implant 20 at the nativevalve (e.g., as described with reference to FIGS. 3A-H).

Tool 100 comprises a shaft 106, a capsule 110, and a balloon 120, whichis typically a non-compliant balloon. Shaft 106 has a centrallongitudinal shaft-axis ax2, which typically is the same as, or iscollinear with, a central longitudinal axis of tool 100. Capsule 110 isdisposed at a distal portion 104 of the tool (e.g., at a distal end ofshaft 106), and comprises an upstream capsule-portion 112 and adownstream capsule-portion 114, and is openable by moving the upstreamcapsule-portion and the downstream capsule-portion apart. Balloon 120 iscoupled to shaft 106, and is disposed within capsule 110 (e.g.,downstream capsule-portion 114 thereof). As shown, tool 100 typicallycomprises a controller and/or handle 108 at a proximal portion 102 ofthe tool.

FIG. 2A shows tool 100 in a closed state, with capsule-portions 112 and114 close to each other (e.g., in contact with each other). FIG. 2Bshows tool 100 in an open state, after capsule 110 has been opened byretracting capsule-portion 114 away from capsule-portion 112. FIG. 2Cshows a longitudinal cross-section of FIG. 2B. FIG. 2D shows the samelongitudinal cross-section as FIG. 2C, but with balloon 120 inflated.For clarity, implant 20 is not shown in FIGS. 2A-D.

As described hereinabove, outer frame 40 of implant 20 is composed of ashape-memory alloy. Flanges 42 are shape-set to protrude radiallyoutward. Upstream support portion 48 is (e.g., arms 49 thereof are) alsoshape-set to protrude radially outward. As described in more detail withreference to FIGS. 3A-H, flanges 42 and upstream support portion 48 aredisposed within, and constrained radially inward by, capsule 110 duringdelivery. For example, flanges 42 may be constrained by downstreamcapsule-portion 114 (e.g., constrained within the downstreamcapsule-portion), and upstream support portion 48 may be constrained byupstream capsule-portion 112 (e.g., constrained within the upstreamcapsule-portion). For delivery of implant 20, tubular frame 30 iscompressed around balloon 120, which will eventually be used to radiallyexpand the tubular frame. Typically, during delivery tubular frame 30 isdisposed within downstream capsule-portion 114. Therefore, inpreparation for implantation of implant 20, an operator typicallycompresses (e.g., “crimps”) tubular frame 30 around balloon 120,radially compresses and at least partly encapsulates flanges 42 withindownstream capsule-portion 114, and radially compresses and at leastpartly encapsulates upstream support portion 48 (e.g., arms 49 thereof)within upstream capsule-portion 112.

In the delivery state of the apparatus, balloon 120 is typicallydisposed within capsule 110, flanges 42 are typically constrained withindownstream capsule-portion 114, and upstream support portion 48 istypically constrained within upstream capsule-portion 112. For someapplications, the term “within” means “entirely within,” i.e., with nopart of the balloon, flange, or upstream support portion disposedoutside of the capsule or capsule-portion. For some applications, theterm “within” means “at least partly within,” i.e., part of the balloon,flange, or upstream support portion may be disposed outside of thecapsule or capsule-portion.

There is therefore provided, in accordance with some applications of theinvention, apparatus comprising:

-   -   a delivery tool, comprising:        -   a shaft, having a shaft-axis;        -   a capsule, disposed at a distal portion of the tool, and            comprising an upstream capsule-portion and a downstream            capsule-portion, the capsule being openable by moving the            upstream capsule-portion and the downstream capsule-portion            apart; and        -   a balloon, coupled to the shaft, and disposed within the            capsule; and    -   a prosthetic valve, comprising:        -   a tubular frame, compressed around the balloon, and disposed            within the capsule;        -   one or more shape-memory flanges, constrained within the            downstream capsule-portion; and        -   a shape-memory upstream support portion, constrained within            the upstream capsule-portion,    -   wherein:        -   the flanges are configured to automatically deflect radially            outward upon exposure of the tubular frame from the            downstream capsule-portion,        -   the upstream support portion is configured to automatically            deflect radially outward upon exposure from the upstream            capsule-portion,        -   the tubular frame is configured to remain compressed around            the balloon upon exposure from the capsule, and        -   while the tubular frame is exposed from the capsule,            inflation of the balloon plastically expands the tubular            frame radially.

Balloon 120 has an upstream (e.g., distal) balloon-portion 122, adownstream (e.g., proximal) balloon-portion 126, and a body (e.g.,intermediary) balloon-portion 124 therebetween. Body balloon-portion 124typically comprises the widest part of balloon 120. Typically, bodyballoon-portion 124 is disposed within lumen 32 of tubular frame 30.That is, for delivery, tubular frame 30 is typically compressed aroundbody balloon-portion 25. As shown in FIG. 2D, when inflated, bodyballoon-portion 124 is typically cylindrical, and balloon-portions 122and 126 typically taper away from the body balloon-portion and fromtubular frame 30. For example, balloon-portions 126 and 126 may beconical or hemispherical.

Typically, balloon 120 is fixed to shaft 106, e.g., by at least one endof the balloon being attached to the shaft. For example, and as shown,balloon-portion 124 may be attached to shaft 106. Tool 100 defines aninflation channel 119 from proximal portion 102 to distal portion 104.For some applications, and as shown, tool 100 comprises a pipe 118through which shaft 106 extends, and channel 119 is defined between thepipe and the channel. For such applications, balloon-portion 126 ofballoon 120 is typically attached to pipe 118, placing balloon 120 influid communication with channel 119 such that the balloon is inflatablevia the channel.

Typically, pipe 118 is fixed with respect to shaft 106. However, bothupstream capsule-portion 112 and downstream capsule-portion 114 aretypically axially movable with respect to shaft 106, such as by one ofthe capsule-portions being attached to a rod 116 that is slidablethrough the shaft, and the other one of the capsule-portions beingattached to a tube (not shown) that is slidable over the shaft. Forexample, and as shown, capsule-portion 112 may be attached to rod 116,and capsule-portion 114 may be attached to the tube. Upstreamcapsule-portion 112 is retractable from over upstream support portion 48by being moved away from balloon 120 (i.e., in an upstream direction),and downstream capsule-portion 114 is retractable from over flanges 42by being moved away from the balloon (i.e., in a downstream direction).

Typically, tool 100 comprises one or more (typically a plurality of)elongate projections 130. Projections 130 are configured to apply anaxial pushing force against implant 20 (e.g., tubular frame 30 thereof),in order to maintain the positioning of the implant during deployment.For example, and as described in more detail with reference to FIGS.3A-H, after flanges 42 are exposed and allowed to expand, the flangesmay be pushed and held against a downstream surface of the native valve(e.g., leaflets thereof), typically until balloon 120 is at least partlyinflated. Typically, each of projections 130 is sufficiently stiff(e.g., axially stiff) that, when pushed against tubular frame 30, it iscapable of applying an axial pushing force of at least 0.5 N, e.g., atleast 5 N, such as at least 10 N—e.g., without the projection buckling.For example, each projection 130 may be capable of applying a pushingforce of 0.5-50 N, e.g., 0.5-20 N (e.g., 0.5-15 N) or 5-50 N (e.g., 5-20N, e.g., 5-15 N, such 5-10 N or 10-15 N). Typically, projections 130 arecollectively capable of applying an axial pushing force of at least 3 N,(e.g., at least 6 N, e.g., at least 20 N, e.g., at least 40 N, such asat least 60 N) to tubular frame 30—e.g., without the projectionbuckling. For example, projections 130 may be collectively capable ofapplying a pushing force of 3-100 N e.g., 3-30 N (e.g., 6-30 N) or40-100 N (e.g., 40-80 N or 60-100 N). For clarity, these axial pushingforce values are as measured with the projection or projections alignedparallel to axis ax1.

During delivery (i.e., in a delivery state of tool 100 and implant 20),projections 130 are typically disposed within downstream capsule-portion114. Each projection 130 has a tip-portion (e.g., a free end) 132, and abase-portion 134. Base-portion 134 is disposed deeper into thedownstream capsule-portion than is tip-portion 132. Projections 130 arearranged circumferentially around shaft-axis ax2, such that tip-portions132 are arranged circumferentially around balloon-portion 126 of balloon120, with the tip-portion of each projection being closer than itscorresponding base-portion 134 to tubular frame 30. Typically, in thedelivery state, tip-portions 132 abut tubular frame 30 (e.g., a proximaland/or downstream surface thereof). However, projections 130 (e.g.,tip-portions 132 thereof) are typically not attached to tubular frame30. Therefore, after expansion of tubular frame 30 and deflation ofballoon 120 (e.g., as described with reference to FIGS. 3A-H),projections 130 can be withdrawn without actively disengaging them fromthe tubular frame.

Tool 100 is typically configured to facilitate continued application, byprojections 130, of the axial pushing force against tubular frame 30while the tubular frame is being expanded, despite the presence oftapered balloon-portion 126. This feature, and its advantages, arediscussed in more detail hereinbelow with reference to FIGS. 4A-B, 5A-B,and 6A-B. Once tubular frame 30 and tip-portions 132 are exposed fromdownstream capsule-portion 114, inflation of balloon 120 both (i)radially expands the tubular frame (e.g., by body balloon-portion 124pressing radially outward against the tubular frame), and (ii) deflectseach of projections 130 radially outward (e.g., by balloon-portion 124pressing radially outward against the projection).

The apparatus may be configured such that projections 130 deflectsimultaneously and/or at the same rate that the tubular frame expands,allowing contact between the projections and the tubular frame to bemaintained. For example, tubular frame 30 may define aframe-circumference, the tip-portions may collectively define aprojection-circumference, and while the tubular frame and thetip-portions are exposed from the downstream capsule-portion, inflationof balloon 120 may increase the projection-circumference at the samerate as it increases the frame-circumference.

Each projection 130 is therefore sufficiently flexible (e.g., radiallyflexible) that it is deflected by a radial force F1 applied by theradial expansion of balloon-portion 126. Nonetheless, as describedhereinabove, each projection 130 is also typically capable of applyingan axial pushing force F2 of at least 0.5 N to tubular frame 30 (e.g.,to overcome an axial resistance force F3, of frame 30 against theprojections, in the opposite direction of force F2). Forces F1, F2, andF3 are indicated in FIG. 4B.

For some applications of the invention, this configuration isfacilitated by each projection 130 being non-isometrically flexible. Forexample, each projection 130 may have a radial stiffness in its radialplane 136, and a lateral stiffness in its lateral plane 138, the lateralstiffness being greater than (e.g., more than twice as great as) theradial stiffness. For clarity, radial plane 136 is a plane on which theprojection and axis ax2 lie, and in which the projection deflects, andlateral plane 138 is typically transverse to the radial plane. Lateralplane 138 may also be tangential to the projection-circumferencecollectively defined by the tip-portions of projections 130.

For some applications of the invention, outward radial force F1 is of agreater magnitude than axial resistance force F3. It is hypothesized bythe inventors that, for at least some such applications of theinvention, F1 being greater than F3 facilitates deflection ofprojections 130 simultaneously with the projections axially pushingtubular frame 30.

For some applications, and as shown, tip-portions 132 are shaped todefine a face that has a greater transverse cross-sectional area thanparts of projection 130 that are closer to base-portion 134. These facesare visible in FIGS. 2C-D. The difference in transverse cross-sectionalarea may be understood by comparing the element labeled “130” in thelower cross-section of FIG. 3B, with the element labeled “130, 132” inthe upper cross-section of FIG. 3B. It is hypothesized by the inventorsthat, due to their greater transverse cross-sectional area, these facesfacilitate application of the axial pushing force to tubular frame 30.

Reference is now made to FIGS. 3A-H, which are schematic illustrationsshowing tool 100 being used to deliver implant 20 to a native valve 10of a heart 4 of a subject, in accordance with some applications of theinvention. Although FIGS. 3A-H show a percutaneous transapical approach,it is to be noted that the scope of the present invention includes otherpercutaneous approaches, such as transatrial, or transluminal (e.g.,transfemoral), mutatis mutandis. It is to be noted that the scope of thepresent invention includes modifications to tool 100 that facilitatethese approaches. Although FIGS. 3A-H show valve 10 as being a mitralvalve, it is to be noted that the scope of the present inventionincludes the native valve being a tricuspid valve, an aortic valve, or apulmonary valve, mutatis mutandis.

While tool 100 and implant 20 are in the delivery state (e.g., withcapsule 110 closed, and implant 20 compressed therewithin), tool 100 istransapically advanced into left ventricle 8 (FIG. 3A). For someapplications, and as shown, tool 100 is positioned (e.g., facilitated byfluoroscopy) such that capsule-portion 112 is disposed between nativeleaflets 12 of valve 10. Capsule-portion 114 is then retracted, in adownstream direction, away from capsule-portion 112, exposing (i) atleast flanges 42 of implant 20, and (ii) at least tip-portions 132 ofprojections 130 (FIG. 3B). Flanges 42 automatically deflect radiallyoutward upon becoming exposed. Typically, and as shown in the inset ofFIG. 3C, flanges 42 are arranged in array 56 around the outside oftubular frame 30, the array defining inter-flange distance D58.Typically, this step also exposes tubular frame 30 from capsule-portion114. As described hereinabove, tubular frame 30 typically does notexpand upon becoming exposed from capsule-portion 114.

FIG. 3B includes two cross-sections. The upper cross-section is at thelevel of contact between projections 130 and implant 20, and thereforeshows tip-portions 132 of the projections arranged circumferentiallyaround uninflated balloon 120, through which shaft 106 extends. Thelower cross-section is further downstream/proximal, closer tobase-portions 134 of projections 130. The lower cross-section alsoshows, for one projection 130, a radial plane 136 and a lateral plane138. As described hereinabove, radial plane 136 is a plane on whichprojection 130 and axis ax1 lie, and in which the projection deflects,and lateral plane 138 is typically transverse to the radial plane.

Flanges 42 are subsequently pressed against a downstream surface ofnative valve 10 by moving implant 20 in an upstream direction (FIG. 3C).This is performed by applying, via projections 130, the axial pushingforce described hereinabove. Typically, flanges 42 are pressed againstleaflets 12 of the native valve.

As shown in FIG. 3C, for applications in which prosthetic valve 22comprises upstream support portion 48, this movement of implant 20includes placing the upstream support portion, constrained bycapsule-portion 112, upstream of native valve 10 (i.e., into left atrium6). For such applications, projections 130 typically facilitateretention of upstream support portion 48 within capsule-portion 112 byobstructing implant 20 from moving axially away from thecapsule-portion.

Subsequently, upstream support portion 48 is exposed fromcapsule-portion 112 and automatically deflects radially outward, e.g.,contacting an upstream surface of native valve 10 (FIG. 3D).

While flanges 42 remain in contact with the downstream surface of thenative valve, and typically while upstream support portion 48 remains incontact with the upstream surface of the native valve, tubular frame 30is plastically expanded radially by inflating balloon 120 (FIGS. 3E-F).For some applications, this is performed while continuing to pressflanges 42 against the downstream surface using projections 130. Asdescribed hereinabove, projections 130 are configured to deflectradially outwardly as tubular frame 30 expands upon inflation of balloon120, and therefore (i) do not inhibit radial expansion of the balloon,and (ii) facilitate optional continued application of the axial pushingforce during inflation of the balloon.

After implant 20 has been implanted and expanded, balloon 120 isdeflated, and tool 100 is removed from the subject, typically afterclosing capsule 110 (FIGS. 3G-H).

Reference is now made to FIGS. 4A-B, 5A-B, and 6A-B, which are schematicillustrations of implant-delivery tools 100, 200, and 300, in accordancewith some applications of the invention. In FIGS. 4A-B, 5A-B, and 6A-B,a generic expandable implant 180 is shown being implanted using therespective tool. For some applications, implant 180 may representtubular frame 30 of implant 20.

FIGS. 4A-B show tool 100 being used with implant 180, e.g., as describedhereinabove for implant 20. The states of tool 100 in FIGS. 4A-Bgenerally correspond to the state of tool 100 in FIGS. 2C-D,respectively, except that in FIGS. 4A-B implant 180 is shown. That is,(i) FIG. 4A shows implant 180 disposed around body balloon-portion 124of balloon 120, with downstream capsule-portion 114 having beenwithdrawn, and balloon 120 not yet inflated, and (ii) FIG. 4B showsballoon 120 having been inflated. FIGS. 5A-B and 6A-B show the samestates (e.g., the same steps of deployment) for tools 200 and 300.

Tool 200 is identical to tool 100, except that it comprises projections230 instead of projections 130. Projections 230 are identical toprojections 130, except that they are more rigid. Projections 330 areidentical to projections 130 except that they are shorter, and thereforedo not extend over balloon-portion 126 to implant 180. (Projections 330may be flexible like projections 130 or rigid like projections 230.) Asdescribed hereinabove, tool 100 is typically configured to facilitatecontinued application, by projections 130, of the axial pushing forceagainst tubular frame 30 while the tubular frame is being expanded,despite the presence of tapered balloon-portion 126. The advantageconferred by projections 130 may be illustrated by the followingcomparison of the results of using tool 200 and/or tool 300, to theresult of using tool 100.

As described hereinabove, body balloon-portion 124 is typicallycylindrical, and balloon-portions 122 and 126 typically taper away fromthe body balloon-portion. A balloon of this shape advantageously canwithstand a greater inflation pressure than can a similar balloon thatis entirely cylindrical (i.e., with flat ends). However, in order toexpand implant 180 evenly, the implant is disposed around bodyballoon-portion 124, which is cylindrical when inflated.

Before inflation of balloon 120, there is no difference between usingtool 100 and using tool 200. When balloon 120 of tool 100 is inflated,projections 130 are pushed radially outward by the balloon, allowingdownstream balloon-portion 126 (over which the projections are disposed)to assume its conical shape, and body balloon-portion 124 to assume itscylindrical shape, thereby evenly expanding implant 180. When inflated,balloon 120 typically fills the lumen of implant 180 uniformly.

In contrast, when balloon 120 of tool 200 is inflated, projections 130are not pushed radially outward by the balloon, and instead constrainballoon-portion 126 (over which the projections are disposed) fromexpanding. Therefore, a downstream region 124 a of body balloon-portion124 is inhibited from fully inflating and joining the rest of the bodyballoon-portion in becoming cylindrical. Therefore, the part of implant180 that is disposed around region 124 a is not expanded to the samedegree as other parts of the implant. That is, implant 180 is notexpanded evenly.

Projections 330 of tool 300 do not extend over balloon-portion 126 toimplant 180, and therefore do not constrain balloon-portion 126 fromexpanding. However, because they do not reach implant 180, they areunable to serve the function of applying the axial force to the implantin order to correctly position the implant during implantation.Furthermore, in some instances, implant 180 may slip with respect toballoon 120 and become positioned over conical balloon-portion 126 or122, which, as described hereinabove, may result in uneven expansion ofthe implant.

Therefore, the particular quality of projections 130 to be both (i)sufficiently rigid to apply the axial force to an implant, and (ii)sufficiently radially flexible to be pushed radially outward by balloon120, provides tool 100 with the ability to both (i) control the positionof an implant, and (ii) to evenly expand the implant.

Reference is made to FIGS. 7A-H and 8A-C, which are schematicillustrations of additional embodiments of implant-delivery tool 100being used to deliver implant 20 to a native valve 10 of a heart 4 of asubject, in accordance with some applications of the invention. In suchembodiments, balloon 120 is configured to be expandable to at least (i)a partially-inflated state and (ii) a further-inflated state. Forexample, proximal portion 102 of tool 100 (e.g., controller/handle 108)may be configured to inflate balloon 120 to a distinctpartially-inflated state, and may be further configured to inflateballoon 120 to a further-inflated state. It is hypothesized by theinventors that regulated inflation of balloon 120, such that the balloonmay be maintained in the partially-inflated state, may facilitate someapplications of tool 100, as described hereinbelow. Since suchembodiments share similarities with those described above in referenceto FIGS. 3A-H, the following description will focus upon aspectsdifferentiating between them and the embodiments described hereinabovein reference to FIGS. 3A-H.

Although FIGS. 7A-H and 8A-C show a transapical approach to a nativemitral valve, these embodiments of the invention may also be modified asnecessary to accommodate alternate approaches to a mitral or othernative heart valve, mutatis mutandis. FIG. 7A shows tool advanced whileimplant 20 is disposed within capsule 110, from which the implant islater exposed. Typically, and as shown in FIG. 7B, flanges 42 deflectautomatically radially outward upon exposure from capsule 110, whereastubular frame 30 typically does not expand upon being partially orentirely exposed from the capsule. Further typically, and as shown,capsule 110 comprises upstream capsule-portion 112 and downstreamcapsule-portion 114, and flanges 42 are exposed from the capsule bymoving the downstream capsule-portion away from the upstreamcapsule-portion. Further typically, flanges 42 are (i) exposed from thedownstream capsule-portion and (ii) arranged in array 56 around theoutside of tubular frame 30, before the flanges are pressed against thedownstream surface of the native valve 10.

For some applications, it may be desirable to at least partially expandtubular frame and/or array 56 of flanges 42, prior to the flangescontacting the downstream surface of native valve 10. FIG. 7C showsinflation of balloon 120 to the partially-inflated state, before flanges42 contact the surface of the native valve 10. Inflation of balloon 120to the partially-inflated state enacts, inter alia, (i) partial radialexpansion of tubular frame 30, and/or (ii) partial increasing ofinter-flange distance D58 defined by array 56. FIG. 7D shows pressing offlanges 42 against a downstream surface of the native valve 10 by movingimplant 20 in an upstream direction, while inter-flange distance D58remains partially increased. Typically, and as shown, this is achievedby moving the implant in the upstream direction while balloon 120remains in the partially-inflated state. In this way, partial inflationof balloon 120 may enable flanges to reach further laterally whilecontacting the downstream surface of native valve 10. It is hypothesizedby the inventors that increasing inter-flange distance D58 defined byarray 56, before flanges 42 press against the downstream surface, mayfacilitate capture of the tissue of native valve 10 (e.g., nativeleaflets 12)—e.g., increasing an amount of the tissue eventuallycaptured between flanges 42 and upstream support portion 48.

Subsequently, upstream support portion 48 is exposed from capsule 110while flanges 42 remain in contact with the downstream surface (e.g.,continue to press against the downstream surface), while inter-flangedistance D58 remains partially increased, and typically while balloon120 remains partially inflated (FIG. 7E). This may be analogous to thestep shown in FIG. 3D, but with inter-flange distance D58 partiallyincreased, and balloon 120 typically being partially inflated.

Subsequently, balloon 120 is further inflated to the further-inflatedstate further radially expanding tubular frame 30 (FIG. 7F). For someapplications, this also further increases inter-flange distance D58 byexpanding array 56. That is, further inflation of balloon 120 may enablethe flanges to reach further laterally than when balloon 120 is in thepartially-inflated state.

FIGS. 7G-H show subsequent deflation of balloon 120 and withdrawal oftool 100, e.g., analogous to FIGS. 3G-H, mutatis mutandis.

For some applications, it may be desirable to expose flanges 42 fromcapsule 110 and/or at least partially expand array 56, while the flangesare disposed upstream of the native valve 10 (e.g., within atrium 6),and to subsequently move the flanges downstream of the native valve(e.g., within ventricle 8) while the flanges remain in this state. FIGS.8A-C relate to such applications.

FIG. 8A shows exposure of flanges disposed upstream of native valve 10,in accordance with some applications of the invention. Prior to this,tool 100 is typically positioned within the heart such that the flangesare disposed, within capsule 110, upstream of the native valve.

For some applications, and as shown in FIG. 8B, balloon 120 is theninflated to the partially-inflated state, while flanges 42 remaindisposed upstream of native valve 10.

Subsequently, tool 100 is moved downstream (proximally, for atransapical approach) until the leaflets are observed (e.g., usingfluoroscopy and/or ultrasound) to coapt upstream of flanges 42 (FIG.8C). It is hypothesized by the inventors that this reduces how fardownstream the flanges become disposed while deployed. That is, theposition of implant 20 at which the leaflets coapt upstream of theflanges represents the minimal depth into the ventricle that the flangesare required to reach in order to subsequently ensnare the leaflets.This therefore reduces the distance that the deployed flanges must bemoved in an upstream direction when subsequently engaging the leaflets.It is hypothesized by the inventors that this reduces the likelihood ofinadvertently or prematurely ensnaring tissue such as chordae tendineae,which might otherwise occur if the deployed flanges were deeper withinthe ventricle, and therefore moved a greater distance, while in theirdeployed state, upstream through the ventricle. Similar techniques aredescribed, mutatis mutandis, in US 2018/0014932 to Hammer et al. and WO2016/125160 to Hariton et al. which are incorporated herein byreference.

For some applications in which flanges 42 are exposed upstream of thenative valve, balloon 120 is partially inflated only after the exposedflanges are moved downstream of the native valve (embodiment not shown).

There is therefore provided, in accordance with some applications of theinvention, method comprising:

-   -   advancing, to the heart:        -   a distal portion of a delivery tool, the delivery tool            including:            -   a shaft that extends to the distal portion of the                delivery tool,            -   a capsule disposed at the distal portion of the delivery                tool, and            -   a balloon, coupled to the shaft, and        -   an implant disposed within the capsule, and including a            tubular frame and an array of shape-memory flanges arranged            around an outside of the tubular frame, the tubular frame            compressed around the balloon, and the flanges constrained            within the capsule;    -   subsequently, exposing the flanges from the capsule such that        the flanges automatically deflect radially outward away from the        tubular frame, and such that the array defines an inter-flange        distance;    -   subsequently, by partially inflating the balloon to a        partially-inflated state:        -   (i) partially radially expanding the tubular frame, and (ii)            partially increasing the inter-flange distance;    -   while the balloon remains in the partially-inflated state,        pressing the flanges against a downstream surface of the native        valve by moving the implant in an upstream direction; and    -   subsequently, by further inflating the balloon to a        further-inflated state, further radially expanding the tubular        frame.

There is further provided, in accordance with some applications of theinvention (e.g., as described in reference to FIGS. 8A-C) a method inwhich:

-   -   exposing the flanges comprises exposing the flanges while the        flanges are positioned upstream of the native valve; and    -   the method further comprises, prior to pressing the flanges        against the downstream surface of the native valve, moving the        exposed flanges to be downstream of the native valve.

It will be appreciated by persons skilled in the art that the presentinvention is not limited to what has been particularly shown anddescribed hereinabove. Rather, the scope of the present inventionincludes both combinations and subcombinations of the various featuresdescribed hereinabove, as well as variations and modifications thereofthat are not in the prior art, which would occur to persons skilled inthe art upon reading the foregoing description.

The invention claimed is:
 1. A method for use at a native valve of aheart of a subject, the method comprising: advancing, to the heart: adistal portion of a delivery tool, the delivery tool including: a shaftthat extends to the distal portion of the delivery tool, a capsuledisposed at the distal portion of the delivery tool, and including anupstream capsule-portion and a downstream capsule-portion, and aballoon, coupled to the shaft, and disposed at least partly within thecapsule, and an implant disposed within the capsule, and including atubular frame and one or more shape-memory flanges, the tubular framecompressed around the balloon, and the flanges constrained within thedownstream capsule-portion; exposing the flanges from the downstreamcapsule-portion such that the flanges automatically deflect radiallyoutward; subsequently, pressing the flanges against a downstream surfaceof the native valve by moving the implant in an upstream direction; andwhile the flanges are in contact with the downstream surface,plastically expanding the tubular frame radially by inflating theballoon.
 2. The method according to claim 1, wherein plasticallyexpanding the tubular frame comprises plastically expanding the tubularframe by radially inflating the balloon while continuing to press theflanges against the downstream surface.
 3. The method according to claim1, wherein advancing the implant comprises advancing the implant whilethe tubular frame is disposed within the downstream capsule-portion, andthe method further comprises exposing the tubular frame from thedownstream capsule-portion.
 4. The method according to claim 3, whereinexposing the tubular frame from the downstream capsule-portion comprisesexposing the tubular frame entirely from the downstream capsule-portionwithout causing the tubular frame to expand.
 5. The method according toclaim 1, wherein the implant further includes a shape-memory upstreamsupport portion, constrained within the upstream capsule-portion, andthe method further comprises, prior to expanding the tubular frame,exposing the upstream support portion from the upstream capsule-portionsuch that the upstream support portion automatically deflects radiallyoutward.
 6. The method according to claim 1, wherein: the implant iscompressed around a body balloon-portion of the balloon, the toolfurther includes one or more projections, each of the projections havinga base-portion and a tip-portion, the projections extend, from theshaft, over at least a downstream balloon-portion of the balloon towardthe tubular frame, such that the tip-portion of each of the projectionsis closer than its corresponding base-portion to the tubular frame, andpressing the flanges against the downstream surface by moving theimplant in the upstream direction comprises pushing the implant in theupstream direction by pushing the tip-portions against the tubularframe.
 7. The method according to claim 6, wherein expanding the tubularframe comprises inflating the balloon such that (i) the bodyballoon-portion radially expands the tubular frame by pressing radiallyoutward against the tubular frame, and (ii) the downstreamballoon-portion deflects the projections radially outward by pressingradially outward against the projections.
 8. The method according toclaim 6, wherein advancing the distal portion of the delivery toolcomprises advancing the distal portion of the delivery tool while theprojections are disposed within the downstream capsule-portion, andwherein the method further comprises, prior to radially expanding thetubular frame, exposing at least the tip-portions of the projectionsfrom the downstream capsule-portion.
 9. The method according to claim 8,wherein exposing at least the tip-portions of the projections from thedownstream capsule-portion comprises exposing at least the tip-portionsof the projections from the downstream capsule-portion prior to pressingthe flanges against the downstream surface of the native valve.
 10. Amethod for use at a native valve of a heart of a subject, the methodcomprising: advancing, to the heart: a distal portion of a deliverytool, the delivery tool including: a shaft that extends to the distalportion of the delivery tool, a capsule disposed at the distal portionof the delivery tool, and a balloon, coupled to the shaft, and animplant disposed within the capsule, and including a tubular frame andan array of shape-memory flanges arranged around an outside of thetubular frame, the tubular frame compressed around the balloon, and theflanges constrained within the capsule; subsequently, exposing theflanges from the capsule such that the flanges automatically deflectradially outward away from the tubular frame, and such that the arraydefines an inter-flange distance; subsequently, by partially inflatingthe balloon to a partially-inflated state: (i) partially radiallyexpanding the tubular frame, and (ii) partially increasing theinter-flange distance; while the balloon remains in thepartially-inflated state, pressing the flanges against a downstreamsurface of the native valve by moving the implant in an upstreamdirection; and subsequently, by further inflating the balloon to afurther-inflated state, further radially expanding the tubular frame.11. The method according to claim 10, wherein inflating the balloon to afurther-inflated state further comprises increasing the inter-flangedistance.
 12. The method according to claim 10, wherein: exposing theflanges comprises exposing the flanges while the flanges are positionedupstream of the native valve; and the method further comprises, prior topressing the flanges against the downstream surface of the native valve,moving the exposed flanges to be downstream of the native valve.
 13. Themethod according to claim 12, wherein partially inflating the ballooncomprises partially inflating the balloon while the flanges arepositioned upstream of the native valve.
 14. The method according toclaim 10, wherein inflating the balloon to the further-inflated statecomprises inflating the balloon to the further-inflated state whilecontinuing to press the flanges against the downstream surface.
 15. Themethod according to claim 10, wherein: advancing the implant comprisesadvancing the implant while the tubular frame is disposed within adownstream capsule-portion of the capsule; exposing the flanges from thecapsule comprises moving the downstream capsule-portion of the capsuleaway from an upstream capsule-portion of the capsule; and the methodfurther comprises exposing the tubular frame from the downstreamcapsule-portion prior to pressing the flanges against the downstreamsurface of the native valve.
 16. The method according to claim 10,wherein: advancing the implant comprises advancing the implant while thetubular frame is disposed within a downstream capsule-portion of thecapsule; exposing the flanges from the capsule comprises moving thedownstream capsule-portion of the capsule away from an upstreamcapsule-portion of the capsule; and the method further comprisesexposing the tubular frame from the downstream capsule-portion withoutcausing the tubular frame to expand.
 17. The method according to claim10, wherein the implant further includes a shape-memory upstream supportportion, constrained within the capsule, and the method furthercomprises, subsequent to pressing the flanges against a downstreamsurface of the native valve, exposing the upstream support portion fromthe capsule such that the upstream support portion automaticallydeflects radially outward.
 18. The method according to claim 10,wherein: advancing the implant disposed within the capsule, the tubularframe compressed around the balloon, comprises advancing the implantdisposed within the capsule, the tubular frame compressed around a bodyballoon-portion of the balloon; the distal portion of the delivery toolincludes one or more projections, each of the projections having abase-portion and a tip-portion; advancing the distal portion of thedelivery tool comprises advancing the distal portion of the deliverytool while the one or more projections extend, from the shaft, over atleast a downstream balloon-portion of the balloon toward the tubularframe, such that the tip-portion of each of the projections is closerthan its corresponding base-portion to the tubular frame; and pressingthe flanges against the downstream surface by moving the implant in theupstream direction comprises pushing the implant in the upstreamdirection by pushing the tip-portions against the tubular frame.
 19. Themethod according to claim 18, wherein inflating the balloon comprisesinflating the balloon such that (i) the body balloon-portion radiallyexpands the tubular frame by pressing radially outward against thetubular frame, and (ii) the downstream balloon-portion deflects theprojections radially outward by pressing radially outward against theprojections.
 20. The method according to claim 18, wherein advancing thedistal portion of the delivery tool comprises advancing the distalportion of the delivery tool while the projections are disposed withinthe capsule, and wherein the method further comprises, prior topartially radially expanding the tubular frame, exposing at least thetip-portions of the projections from the capsule.